What is bilateral oophorectomy (removal of both ovaries) when combined with adhesiolysis (surgical division or removal of adhesions)?

Bilateral Oophorectomy Combined with Adhesiolysis: Definition and Clinical Context

Bilateral oophorectomy combined with adhesiolysis is a surgical procedure involving the removal of both ovaries (bilateral oophorectomy) along with the surgical division and removal of adhesions (scar tissue bands) that bind pelvic organs together. This combined approach is most commonly performed in the context of gynecologic malignancies, severe endometriosis, or chronic pelvic pain conditions where adhesions contribute to symptoms or complicate the primary surgical objective.

Surgical Components

Bilateral Oophorectomy

• Involves complete removal of both ovaries, typically performed as part of bilateral salpingo-oophorectomy (BSO), which includes removal of both fallopian tubes and ovaries 1
• In cancer staging procedures, this requires complete excision of the lumbar-ovarian vessels bilaterally 2
• The procedure eliminates ovarian cancer risk definitively, which cannot be achieved through screening alone 3

Adhesiolysis

• Involves surgical division or excision of adhesions—fibrous bands that form between pelvic organs following inflammation, infection, previous surgery, or endometriosis 4
• During cancer surgery, any peritoneal surface or adhesion suspicious for harboring metastasis should be selectively excised or biopsied 1
• In endometriosis cases, adhesiolysis is performed to restore normal pelvic anatomy and reduce pain 5

Clinical Indications

Gynecologic Malignancies

• For epithelial ovarian cancer: Total hysterectomy with bilateral salpingo-oophorectomy is standard, with all peritoneal surfaces visualized and suspicious adhesions excised or biopsied 1
• For early-stage disease confined to the ovary: Adhesions should be evaluated as dense adhesions may upstage disease from FIGO stage I to stage II, requiring more aggressive treatment 1
• The procedure allows thorough evaluation of the abdominal cavity to detect occult disease 3

Endometriosis with Chronic Pelvic Pain

• Hysterectomy with bilateral oophorectomy combined with endometriosis excision decreases recurrence rates and surgical reoperations compared to resection of endometriotic lesions alone 6
• Patients who underwent hysterectomy alone (ovarian conservation) were more likely to require reoperation compared to those who underwent hysterectomy with bilateral oophorectomy (13% vs 5%), with adhesiolysis being one of the most common reoperations 4
• Bilateral oophorectomy combined with hysterectomy is effective for chronic pelvic pain due to venous congestion that has failed medical treatment 7

High-Risk Cancer Prevention

• For women with Lynch Syndrome (MLH1, MSH6, or PMS2 mutations), hysterectomy with BSO significantly reduces cancer risk 3
• Women with BRCA mutations or family history of ovarian cancer gain substantial benefit from prophylactic BSO after menopause 3

Surgical Technique Considerations

Approach to Adhesions in Cancer Surgery

• A vertical midline abdominal incision provides optimal exposure for patients with suspected malignant ovarian neoplasm 1, 2
• All peritoneal surfaces must be visualized, and any adhesion suspicious for metastasis should be selectively excised or biopsied 1
• In the absence of suspicious areas, random peritoneal biopsies should be taken from the pelvis, paracolic gutters, and undersurfaces of the diaphragm 1

Approach to Adhesions in Benign Disease

• Laparoscopic approaches are preferred over laparotomy when conservatively treating endometriosis, offering shorter hospital stays and fewer moderate-to-severe postoperative complications 3, 8
• Transient ovariopexy (temporarily suspending ovaries to the anterior abdominal wall) can reduce postoperative adhesion reformation in severe pelvic endometriosis, though this is only relevant when ovaries are preserved 5

Important Clinical Caveats

Reoperation Risk

• When oophorectomy as a reoperation was removed in sensitivity analysis, the difference in reoperation rates between ovarian conservation and bilateral oophorectomy was partially attenuated (6% vs 3%), suggesting adhesiolysis alone accounts for some but not all reoperations 4
• Despite radical treatment with hysterectomy and bilateral oophorectomy, approximately 15% of patients with endometriosis will have persistent pain 6

Hormone Replacement Considerations

• Taking into account the multiple adverse effects of early menopause on life expectancy and quality of life, ovarian preservation should be discussed with patients undergoing hysterectomy for deep endometriosis 6
• However, approximately 40% of patients do not fill hormone replacement therapy prescriptions after hysterectomy with bilateral oophorectomy, which may have significant health consequences 4
• Menopausal hormone therapy does not appear to increase symptoms of endometriosis after surgical castration and is not contraindicated 6

Documentation Requirements

• The operative report must include precise details of operative findings and procedures performed, including documentation of adhesions, their location, and whether they were excised or biopsied 2, 9
• For cancer cases, documentation should specify the extent of disease, quality of excision margins, and completeness of cytoreduction 2